Ileal electrical stimulation

ABSTRACT

The disclosure is a method of treatment for obesity, in an individual in need thereof comprising positioning stimulatory electrodes in the distal small intestines or ileum, and administering electrical stimulation in trains of pulses or repetitive pulses, where the electrical stimulation is effective, at least in part in, stimulating the vagal afferent and efferent activity, of the distal small intestines or ileum, in the individual. The stimulation of the vagal afferent and efferent activity leads to the regulation of the ileal brake. Specifically, the electrical stimulation is provided in trains of pulses. Also, described is a method of treatment for functional gastrointestinal disease by ileal electrical stimulation. Further this invention provides a method of treatment for an eating disorder comprising administering ileal electrical stimulation effective, at least in part, in stimulating the vagal and sympathetic pathways. The stimulatory electrodes are placed by laparoscopic, endoscopic or surgical means.

RELATED APPLICATION

This application claims priority to U.S. patent application 61/024,743, filed on Jan. 30, 2008, which is specifically incorporated by reference in its entirety herein without disclaimer. This application also claims priority to PCT application PCT/US2009/032662, filed Jan. 30, 2009, which is specifically incorporated by reference in its entirety herein without disclaimer.

BACKGROUND

Electrical stimulation of the gastrointestinal (GI) tract is analogous to pacing of the human heart. Organs of the GI tract have their own natural pacemakers, and the electrical signals they generate can be altered by externally delivering certain types of electric currents via intraluminal or serosal electrodes to certain areas of the GI tract. Abnormalities in gastric slow waves lead to gastric motor disorders and have been frequently observed in patients with functional disorders of the gut, such as gastroparesis, functional dyspepsia, anorexia and etc. Therefore, electrical stimulation of GI organs is a valuable alternative to medication and surgical approaches in the treatment of GI dysfunctions.

Obesity is a complex, multifactorial and chronic condition characterized by excess body fat. Obesity results from an imbalance between energy expenditure and caloric intake. Although the causes of this imbalance are not completely understood, genetic and/or acquired physiologic events and environmental factors are important. The adverse health effects of obesity, and more particularly morbid obesity, have become well-known in recent years. Such adverse health effects include, but are not limited to, cardio-vascular disease, diabetes, high blood pressure, arthritis, and sleep apnea. Generally, as a patient's body mass index rises, the likelihood of suffering the adverse health effects of obesity also rises.

Often, surgery has been the only therapy that ensures real results in patients who have exceeded BMI values close to, or in excess of, 40 kg/m². Modern surgical procedures generally entail either (1) the reduction of gastric compliance, with the aim of limiting the subject's ability to ingest food, or (2) the reduction of the food absorption surface by shortening or bypassing part of the digestive canal. In some case, both aims are sought through the same surgical procedure. The risk and invasiveness factors of currently available surgeries are often too great for a patient to accept to undergo surgical treatment for treatment of obesity. Accordingly, there is a need for less invasive, yet effective treatment procedures for the morbidly obese. Also, since the current surgical procedures are currently indicated only for those patients having a BMI of 40 or greater, or 35 or greater, when co-morbidities are present, it would be desirable to provide a less invasive procedure that would be available for slightly less obese patients, e.g., patients having a BMI of 30 to 35 who are not indicated for the currently available surgical procedures.

A need continues to exist for additional feasible and suitable means to treat obesity. Likewise, a need continues to exist for additional feasible and suitable means to treat other gastrointestinal tract disorders.

SUMMARY

Provided herein is a method of treatment for obesity, in an individual in need thereof, the method comprising positioning a pair of stimulatory electrodes in contact with the distal small intestine or ileum of the individual; and administering electrical stimulation, where the electrical stimulation is effective, at least in part in, stimulating the vagal afferent and efferent activity, of the distal small intestines or ileum, in the individual.

Further, provided herein is a method of treatment for functional gastrointestinal disorders, in an individual in need thereof, comprising positioning stimulatory electrodes in contact with the distal small intestines or ileum, and administering electrical stimulation, where the electrical stimulation is effective, at least in part in, altering gastric emptying.

Also, provided is a method of treatment for an eating disorder, in an individual in need thereof, the method comprising positioning stimulatory electrodes in contact with the distal small intestine or ileum; and administering electrical stimulation, where the electrical stimulation is effective, at least in part in, stimulating the vagal afferent and efferent activity, of the distal small intestines or ileum, in the individual.

Further, provided is a method of treatment for a metabolic disease, in an individual in need thereof, comprising positioning stimulatory electrodes in contact with the distal small intestine or ileum, and administering electrical stimulation where the electrical stimulation is effective, at least in part in, stimulating the vagal afferent and efferent activity, of the distal small intestines or the ileum, in the individual.

The details of one or more embodiments of the disclosure are set forth in the accompanying drawings and the description below. Other features, objects, and advantages of the disclosure will be apparent from the description and drawings, and from the claims.

BRIEF DESCRIPTION OF THE DRAWINGS

In order that the manner in which the above recited and other enhancements and objects of the disclosure are obtained, a more particular description of the disclosure briefly described above will be rendered by reference to specific embodiments thereof, which are illustrated, in the appended drawings. Understanding that these drawings depict only typical embodiments of the disclosure and are therefore not to be considered limiting of its scope, the disclosure will be described with additional specificity and detail through the use of the accompanying drawings in which:

FIG. 1 illustrates effects of ileal electrical stimulation (IES) on gastric tone.

FIG. 2 shows effects of ileal electrical stimulation (IES) on gastric emptying.

FIG. 3 illustrates the location of the stimulation electrodes in the distal small intestines or the ileum in an embodiment.

FIG. 4 illustrates the placement of the electrodes and stimulators in an embodiment.

FIG. 5 A-F shows various electrode leads with radially spaced arms in various configurations inserted into and through the hollow bore of a needle.

FIG. 6 A, B shows electrode leads with radially spaced arms inserted through the skin, panniculus and gastrointestinal wall after removal of insertion needles. FIG. 6C shows bridged insertion needles.

FIG. 7A-D shows methods and devices for using a needle with a guide rod for electrode leads with radially spaced arms.

FIG. 8A shows a method of placing gastrointestinal leads with a percutaneous endoscopic gastronomy type device. FIG. 8B shows conductive wire through an electrode lead with an insertion axis and a plurality of radially spaced arms.

LIST OF REFERENCE NUMERALS

-   -   1 electrode lead with an insertion axis     -   2 needle     -   3 hollow bore     -   4 entrance tip     -   5 first or a single pair of radially spaced arms     -   6 second or additional pair of radially spaced arms     -   7 bridge     -   8 skin     -   9 panniculus     -   10 gastrointestinal wall     -   11 guide rod     -   12 skin bolster     -   13 gastric bolster     -   14 plurality of electric leads     -   15 lead ends     -   16 conductive wire     -   17 second needle

DETAILED DESCRIPTION OF THE DISCLOSURE

The particulars shown herein are by way of example and for purposes of illustrative discussion of the preferred aspects of the present disclosure only and are presented in the cause of providing what is believed to be the most useful and readily understood description of the principles and conceptual aspects of various embodiments of the disclosure. In this regard, no attempt is made to show structural details of the disclosure in more detail than is necessary for the fundamental understanding of the disclosure, the description taken with the drawings and/or examples making apparent to those skilled in the art how the several forms of the disclosure may be embodied in practice.

The following definitions and explanations are meant and intended to be controlling in any future construction unless clearly and unambiguously modified in the following examples or when application of the meaning renders any construction meaningless or essentially meaningless. In cases where the construction of the term would render it meaningless or essentially meaningless, the definition should be taken from Webster's Dictionary, 3^(rd) Edition.

As used herein, all percentages are percentages by weight, unless stated otherwise.

As used herein, the “gastrointestinal tract” (GI tract) in certain instances may refer to the “gut” or the “alimentary canal” that is a continuous, coiled, hollow, muscular tube that winds through the ventral body cavity. It is open to the external environment at both ends. In a human, its organs (gastrointestinal organs) generally include the mouth, pharynx, esophagus, stomach, small intestine (duodenum, jejunum, and ileum), and large intestine (cecum, appendix, colon, rectum, and anal canal). The large intestine leads to the terminal opening, or anus.

The “gastrointestinal wall” in certain instances may refer to the continuous, coiled, hollow, muscular tube that is the gastrointestinal tract. The wall generally defines the center (lumen) of the GI tract (the hollow portion of the tube). The wall has a thickness defining an interior wall adjacent to the center of the GI tract and an exterior wall.

As used herein, “gastrointestinal action” in certain instances may refer to any GI actions. Thus, gastrointestinal action includes, for example, gastrointestinal electrical activity, gastrointestinal contractile activity (such as stomach contractile activity), gastrointestinal motility, gastric emptying, gastrointestinal pressure, gastrointestinal impedance, and afferent nerve activity (including vagal nerve, sympathetic nerves, and spinal nerves).

“Visceral pain” in certain instances may refer to pain or discomfort that is centered in the upper abdomen and/or the lower abdomen, for example, pain associated with dyspepsia or pain due to irritable bowel syndrome. In one aspect, the visceral pain is caused by distention or other noxious stimulation of a gastrointestinal organ.

“Reducing” visceral pain in certain instances may refer to reducing or eliminating one or more of the symptoms of visceral pain. Methods of measuring the reduction of visceral pain in a non-human subject include measuring a number of behavioral responses to visceral pain before and after gastrointestinal electrical stimulation is provided. In animals the responses measured include rapid breathing, nausea, vomiting, burping, licking lips, hi a human subject, the reduction and/or elimination of symptom of visceral pain is measured by evaluation of the subject by, for example verbal expression of intensity of pain on a scale such as 0-10.

Although not meaning to be bound by theory, gastrointestinal pain of a subject is largely mediated via the sympathetic (spinal cord) pathway. Gastrointestinal electrical stimulation, as used in the present disclosure, alters sympathetic nerves, such as the spinal afferent neurons. Accordingly, gastrointestinal electrical stimulation treats or reduces pain of a subject by blocking the sympathetic pathway of the subject.

A subject in certain instances may refer to an animal, including a human, subject. For non-human animal subjects, the particular structure of the GI tract may differ from that of a human. For such non-human animal subjects, the gastrointestinal tract, as used herein, refers to that non-human animal's known GI tract and GI organs. It is understood that the first step of the present disclosure includes selecting a subject which would benefit from the method of the subject, such as, for example, selecting a subject who is suffering from gastrointestinal pain.

An “optimum level” in certain instances may refer to a pre-determined target, which is determined based on the desired outcome. For example, in GES (see below), the definition of optimization is based on an optimal combination of efficacy, safety and feasibility. That is, the optimal GES settings are those that result in a significant reduction in pain (efficacy) but do not induce undesired symptoms, such as nausea or vomiting (safety) with minimal energy (maximally feasible for an implantable device). Iterative adjustments of stimulation parameters are made to achieve this result. For any particular gastrointestinal action, an “optimum level” or desirable level can be determined by monitoring the appropriate GI action. As another example, an appropriate amount of GI pressure at the esophageal sphincter can be determined which prevents reflex of stomach juices into the esophagus, while still allowing the passage of food items into the stomach. With this predetermined “optimum level”, a stimulatory electrode can be established with a sensor to maintain this optimum level. The optimum level is thus fact and subject specific, but readily determinable with routine experimentation, taking into account the goal of an optimal combination of efficacy, safety and feasibility.

A “stimulatory electrode” in certain instances may refer to a conductor of electricity through which current enters a medium (a subject), whereas a “sensor” refers to a conductor of electricity through which current leaves a medium (a subject). Typically, for gastrointestinal uses, the stimulatory electrodes and sensors are constructed of Teflon™-insulated wires such as are used for cardiac pacing wires. The stimulatory electrode is electrically connected (i.e., conductively connected) to a source of electrical current (often referred to as a pacemaker where a set pattern of electrical current is delivered), and the sensor is electrically connected to a device for determining the level of electrical current “sensed” by the sensor (an electrical recorder, for example). The stimulatory electrode is thus used to “generate” electrical current and the sensor is thus used to “detect” electrical current. Note that the stimulatory electrode can be used to “generate” electrical current, which is itself a defined “gastrointestinal action”, but the generation of electrical current can also produce other gastrointestinal actions (such as, for example, stomach contraction or esophageal pressure). The language “generating” GI action is thus intended to cover both concepts, i.e. the generation of the initial electrical current and the ultimate gastrointestinal action which is “generated” as a result of the current (i.e. the contraction or pressure).

“Operatively connected” in certain instances may refer to the connection between the stimulatory electrode and the sensor, and indicates that the operation of one is connected to the operation of the other. In particular, the sensor connects to a device which determines the level of electrical current sensed by the sensor. A representation of that level is then fed to the source of electrical current that is electrically connected to the stimulatory electrode. The source of electrical current is provided with a programmable computer circuit that enables the level from the sensor to determine, or dictate, the operation of the source (i.e., electrical current is generated by the source and fed through the stimulatory electrode in response to and an in relation to the amount of the level of electrical activity sensed by the sensor). Thus, the “operatively connected” stimulatory electrode and sensor enable the retrograde feedback concept to occur.

“Positioning” a stimulatory electrode or a sensor in certain instances may refer to placement of the stimulatory electrode or sensor on or in a subject. Placement or positioning of stimulatory electrodes can be accomplished by laparoscopic, endoscopic, colonoscopic or surgical means. In general, laparoscopic placement of electrodes is performed by inserting a scope through one trocar or sheath and the electrode through one or more other trocars or sheaths. The trocars are sleeves which are inserted through a body opening which may be a surgically made opening or portal through the skin, muscle and peritoneal membrane. Often the body cavity, such as the abdominal peritoneal area is inflated with low pressure carbon dioxide. An insufflation pressure of about 12 millimeters of HG or less is maintained during the operation by a sealing membrane located in the trocar opening comprising a thin rubber material having a small diameter hole of approximately 3 millimeters therein. The electrodes are inserted through the membrane hole which stretches to accommodate the larger size thereby forming and effective seal.

Endoscopic placement of the electrodes can be accomplished by either using the endoscope for both visualization as well as insertion of electrodes or by endoscopic visualization to guide insertion of the electrodes. For the latter method, the conscious patient is sedated and an endoscope is inserted into the distal small intestines or the ileum via the mouth. Then, a sharp, long and small needle with a hole in the middle (similar to needles used for the placement of percutaneous endoscopic gastronomy tubes) is inserted into the distal small intestines or the ileum by puncturing the skin. A Teflon™-insulated wire, peeled off at the distal portion, is then extended, under endoscopic observation, into the distal small intestines or the ileum, via the hole of the needle. The exposed or peeled off portion of the inserted Teflon™-insulated wire serves as an electrode. The needle is removed after the insertion of the wire. The wire has an engaging means. The engaging means allow for engagement of the wire with the mucosa, when the wire is slowly pulled from the exterior, and stops it from being further pulled out. On the external end the wire is attached to the abdominal skin and protected from infection. This placement of the electrodes can also be guided via colonoscopic visualization.

The engaging means for the electrode refers to any suitable means that would allow for the successful engagement of the electrodes to the mucosa. These include but are not limited to barbs, expandable hooks, suction based fasteners arranged at the distal tip of the electrodes, and/or the like, as would be understood by one of ordinary skill in the art.

“Periodically” in certain instances may refer to evenly or unevenly spaced time intervals.

“Differs from” in certain instances may refer to a statistically significant variation between two compared values, and therefore does not always require a difference in orders of magnitude. It should be apparent that where small values are compared, statistically significant variations can likewise be very small, and where large values are compared, statistically significant variations can be large. Conversely, “substantially equals” refers to a statistically insignificant variation between two compared values.

“Electrical field stimulation” in certain instances may refer to the generation of an “electrical field”, which indicates that the area of distribution of the electrical current from the stimulation encompasses the entire area between and/or surrounding two or more stimulatory electrodes, and “field” is used to imply that the two or more stimulatory electrodes are positioned at least about three centimeters apart (thus the term “field” to differ from prior stimulations where the two electrodes of a pair are positioned in close proximity to one another and do not generate a “field”).

A “device”, in various embodiments, in certain instances may refer to any suitable item which can readily be and is desirable to be placed in the GI tract. Such devices can include, for example, stimulatory electrodes and sensors for use in the GES method of the subject disclosure. Such devices could also include a small balloon to be used to provide pressure within the esophagus or small/large intestine. A small gauge for measurement of pressure could be a device in accordance with the subject disclosure.

Electrical stimulation refers to an electrical signal, which includes train of pulses, and repetitive pulses. A train of pulses refers to a method in which the stimulus is composed of repetitive trains of short pulses derived from a combination of two signals, a) a continuous short pulse with high frequency (in the order of 5 to 150 Hz), and b) control signal to turn the pulses on or off, such as “X” seconds on and “Y” seconds off. The addition of “X” and “Y” then determines the frequency of the pulse train. A frequency approximately equal to the physiologic frequency of stimulation will be performed using trains of pulses. The train will be set with a train on time from 0.1 s to 10 s, train off time from Os to 10 s, and pulses in each train with amplitude of 0.1 mA to 2 OmA (or voltage equivalent), width of 0.1 ms to 20 ms and frequency of 0.1 Hz to 200 Hz. The electrical stimulation is composed of repetitive long train of pulses with a width of 5 ms to 2000 ms, amplitude of 0.1 mA to 2 OmA and frequency of 1 pulse/min to 60 pulses/min. The methods of providing electrical field stimulation to a gastrointestinal organ are disclosed in WO/2001/076690 (GASTROINTESTINAL ELECTRICAL STIMULATION) which is hereby incorporated by reference herein. A discussion of pulse-train electrical stimulation is provided in Zhang et al., 2006, which is hereby incorporated by reference herein.

“Long pulse” electrical stimulation refers to an electrical signal which has a long width, such as in the order of from about 1 to about 900 milliseconds, and has a frequency equal to or a few times higher than the physiologic frequency of the gastric slow wave of the subject. For treating gastrointestinal motility disorders, the frequency of stimulation is typical equal to the frequency intrinsic slow waves; whereas for treating obesity, it is usually a higher than the physiological frequency of the gastric slow waves.

“Short pulse electrical stimulation refers to an electrical signal which has a short width, such as in an order of from about 50 to about 999 microseconds, or about 100 to about 300 microseconds and having a frequency from about 5 Hz to about 500 Hz.

Synchronization or synchronized refers to applying the long pulse and/or short pulse electrical stimulation substantially concurrently with the occurrence of the gastric slow wave of the subject.

Electrical stimulation of the gastrointestinal tract has been proposed to treat motility related disorders and other gastrointestinal diseases. The electrical stimulation has been proposed in a number of forms, such as, e.g., pacing, electrical contractile stimulation or other stimulation, e.g., to treat nausea or obesity. Electrical pacing of the gastrointestinal tract is generally defined as a periodic electrical stimulation that captures and/or controls the frequency of the pacesetter potential or slow wave activity of the intestinal organ (including in a retrograde direction). Electrical contractile stimulation generally refers to stimulation that directly causes or results in muscular contraction associated with the gastrointestinal tract. There have been a number of reports on Gastric electrical stimulation for the treatment of gastrointestinal motility disorders in both dogs and humans (U.S. Pat. Nos. 5,423,872, 5,690,691, and 5,836,994; PCT International Publication No. WO 99/30776; Bellahsene et al. 1992; Mintchev et al. 1998; Mintchev et al. 1999; Mintchev et al. 2000; Chen et al. 1998; Chen et al. 1995c). These disorders are characterized by poor contractility and delayed emptying and the aim of electrical stimulation in this setting is to normalize the underlying electrical rhythm and improve these parameters. Gastric emptying plays an important role in regulating food intake. Several studies have shown that gastric distention acts as a satiety signal to inhibit food intake (Phillips and Powley 1996) and rapid gastric emptying is closely related to overeating and obesity (Duggan and Booth 1986). Obese subjects have a more rapid emptying rate than non-obese subjects (Wright et al. 1983). In general, this is done by antegrade or forward gastric (or intestinal) stimulation. Previous work on antegrade gastrointestinal stimulation has been focused on its effects on gastric myoelectrical activity, gastric motility, and gastric emptying, (Lin et al. 1998; Eagon and Kelly 1993; Hocking et al. 1992; Lin et al. 2000a; McCallum et al. 1998; Miedema et al. 1992; Qian et al. 1999; Abo et al. 2000; Bellahsene et al. 1992).

Similar to the stomach, the small intestine can also be electrically stimulated. See Chen and Lin, 2003, Reiser et al., 1991, Lin et al., 2000 and Sarr et al., 1981.

The small intestine is the longest section of the digestive tract (approx 17 feet) and is divided into three segments: the duodenum, jejunum and ileum, each of which performs different digestive functions. Roughly 7-5 feet in length, the ileum is the final section of the small intestine, linked to the large intestine by the ileocecal valve. The main function of the ileum is to absorb nutrients. Progressive reduction of slow wave frequency ensures increased contact time, retarded flow and promotes absorption. Bile is also absorbed here and returns to the liver through blood vessels in the intestinal walls. Specialized contractile patterns in the distal small intestines or the ileum and proximal colon contribute to function. Ileal smooth muscles possess special motor properties. The distal small intestines or the ileum has unique propulsive properties dependent on its neural connections rather than being caused by the presence of specially adapted longitudinal or circular muscle. Distinctive anatomical features of the distal small intestines or ileum include a greater density of ganglia within the myenteric plexus.

The ileal brake is a neurohormonal feedback mechanism, whereby ingested food activates distal intestinal signals that inhibit gastric emptying and proximal gastrointestinal motility thereby enhancing nutrient digestion and absorption in the proximal small intestine and preventing nutrient overflow into the distal gut. Studies have shown that delayed gastric emptying and gastric distention result in reduced food intake. Gastric emptying plays an important role in regulating food intake and rapid gastric emptying is closely related to overeating and obesity. Digestion and absorption of a meal are time-intensive events that may easily exceed 4 to 6 hours in duration. In the absence of nutrient-triggered transit control, rapid movement of the luminal content from the stomach to the rectum may impair digestion and absorption by reducing time available for assimilation of food. The sensation of satiety is transmitted to the brain through afferent sensory fibers in the vagus nerves. Peptide YY (PYY) release triggered by ileal fat perfusion has been reported. Intravenous administration of polyclonal PYY antibody abolishes the slowing of intestinal transit by distal gut fat, thus confirming the role of PYY in the fat-induced ileal brake. Glucagon gene products, specifically GLP-I and GLP-2 are also important in mediating the ileal brake. Further, intact vagal afferent and efferent activity of distal intestinal or ileal L-cell release of GLP-I and GLP-2 has been demonstrated.

Thus, in addition to digesting and assimilating nutrients, the intestine and associated visceral organs play a key sensing and signaling role in the physiology of energy homeostasis. Signals reflecting energy stores, recent nutritional state, and other parameters are integrated in the central nervous system, particularly in the hypothalamus, to coordinate energy intake and expenditure. These discoveries have led to exploration of novel routes for obesity control, some of which involve gut-derived pathways.

With these definitions in mind, provided herein is a method of treatment for obesity, in an individual in need thereof, the method comprising positioning a pair of stimulatory electrodes in contact with the distal small intestine or ileum of the individual; and administering electrical stimulation, where the electrical stimulation is effective, at least in part in, stimulating the vagal afferent and efferent activity, of the distal small intestines or ileum, in the individual. In general, the stimulation of the vagal afferents and efferents activity regulates the ileal brake. The electrical stimulation is administered in trains of pulses. Specifically, the electrical stimulation is composed of trains of pulses, with a train on time from 0.1 s to 10 s, train off time from 0 s to 10 s, and pulses in each train with amplitude of 0.1 mA to 20 mA (or voltage equivalent), width of 0.1 ms to 20 ms and frequency of 0.1 Hz to 200 Hz. The electrical stimulation is composed of repetitive long train of pulses with a width of 5 ms to 2000 ms, amplitude of 0.1 mA to 20 mA and frequency of 1 pulse/min to 60 pulses/min. The positioning of stimulatory electrodes is by laparoscopic, endoscopic or surgical procedures. In general the pair of stimulatory electrodes are positioned about 1 cm to 10 cm apart. Specifically, the individual suffers from a functional gastrointestinal disease. The functional gastrointestinal disease is selected from the group consisting of functional dyspepsia, irritable bowel syndrome, diarrhea, constipation, fecal incontinence, visceral hypersensitivity and visceral pain. Moreover, the individual suffers from an eating disorder. In general, the eating disorder is selected from the group consisting of bulimia, obesity and compulsive eating. Also, the individual suffers from diabetes.

Further provided is a method of treatment for functional gastrointestinal disease, in an individual in need thereof, the method comprising positioning stimulatory electrodes in contact with the distal small intestine or ileum; and administering electrical stimulation, where the electrical stimulation is effective, at least in part in, regulating gastric emptying. In general, the electrical stimulation activates the vagal afferent and efferent activity, of the distal small intestines or ileum, in said individual. Specifically, the stimulation of the vagal afferents and efferents activity regulates the ileal brake.

Optionally the methods above may additionally include positioning a sensor relative to the subject so that the sensor senses the level of total electrical stimulation. In certain aspects, the sensor may be operatively connected to the electrode. Optionally, the method may include periodically detecting the level of electrical stimulation with the sensor. Still further, the method may include periodically generating non-naturally occurring electrical stimulation with the electrode.

Certain aspects of the disclosure concern methods of providing electrical field stimulation to a gastrointestinal organ. Such a method may comprise positioning a first electrode in a gastrointestinal organ and positioning a second electrode in the same part or a different part of the gastrointestinal organ. The electrodes may be stimulatory electrodes. Optionally, the electrodes may be spaced apart from one another. Optionally, the second electrode may be placed 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10 mm or 20, 30, 40, 50, 60, 70, 80, 90 mm or 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10 cm or some range therein from the first electrode. In certain cases, the second electrode may be preferably placed at least about two centimeters from the first electrode. Optionally, the method may further comprise electrically stimulating the gastrointestinal organ simultaneously through the first and the second stimulatory-electrodes, wherein one of the first and the second stimulatory electrodes has a positive polarity and wherein the other one of the first and the second stimulatory electrodes has a negative polarity, thereby providing electrical field stimulation to the gastrointestinal organ between the first and the second stimulatory electrodes.

Certain aspects of the disclosure concern methods of providing electrical potential gradient in a gastrointestinal organ. Such a method may comprise positioning a first electrode in a gastrointestinal organ and positioning a second stimulatory electrode in the gastrointestinal organ. The electrodes may be stimulatory electrodes. Optionally, such a method further comprises the second electrode being positioned at a distance from the first electrode. Optionally, the second electrode may be placed 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10 mm or 20, 30, 40, 50, 60, 70, 80, 90 mm or 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10 cm or some range therein from the first electrode. In certain cases, the second electrode may be preferably placed at least about two centimeters from the first electrode. Optionally the method further comprises electrically stimulating the gastrointestinal organ simultaneously through the first and the second stimulatory electrodes. Preferably in such a method, voltage generated by the first electrode differs from voltage generated by the second electrode. Such a method may result in the providing of an electrical potential gradient in the gastrointestinal organ between the first and the second electrodes.

Certain aspects of the disclosure provide methods of treatment by positioning a plurality of electrodes in a gastrointestinal organ. Such a method may comprise positioning a first pair of bipolar stimulatory electrodes in contact with a gastrointestinal organ. Optionally the placement is along the afferent vagus neural pathway. Optionally, such a method further comprises positioning a second pair of bipolar stimulatory electrodes in contact with a gastrointestinal organ along the afferent vagus neural pathway. Optionally, when the use of two pairs of electrodes is contemplated, such a method further comprises administering a phased pulse regimentation of the electrical stimulation which progresses from the first pair of electrodes to the second pair of electrodes. Such a method may comprise placement of the electrodes by laproscopic, endoscopic or surgical procedures, through the bore of a needle or some combination thereof. Such a method may further comprise electrical stimulation in repetitive pulse trains.

Certain aspects of the disclosure provide methods of placing a device in or through a gastrointestinal organ of a subject. Such a method may comprise placing the device from the exterior of the subject. Optionally, such a method further comprises inserting at least part of a needle, such as an end of a needle, from the exterior of a subject into the gastrointestinal tract of the subject. Optionally, such a method further comprises a needle having an interior bore. In such a method, wherein insertion into a gastrointestinal organ is contemplated the gastrointestinal tract of the subject may be considered to have center defined by a wall. The wall of the gastrointestinal tract may be considered to have a thickness defining an interior wall adjacent to the center and an exterior wall. The method may further comprise inserting a needle, such as a needle having an interior bore, through the wall of the gastrointestinal tract and into the center of the gastrointestinal tract. The method may further comprise inserting a device through the interior bore of the needle. Optionally, the method contemplates that they device may have engaging means to engage the thickness of the wall of a gastrointestinal organ of the gastrointestinal tract. In methods wherein a needle with an interior bore and a device with an interior wall engaging means is contemplated, the method may further comprise inserting the device at least until the interior wall engaging means extends beyond the interior bore of the needle. Optionally, such a method further comprises removing the needle. Optionally, such a method further comprises retracting the device until the interior wall engaging means engages the interior wall of the gastrointestinal tract of a gastrointestinal organ of the subject. Alternatively, such a method further comprises retracting the device until the interior wall engaging means engages the thickness of a gastrointestinal organ.

The methods of placing a device described above may optionally further comprise inserting at least part of a needle, such as an end of a needle, from the exterior of a subject into the gastrointestinal tract of the subject or into the thickness of a gastrointestinal organ of a subject. Optionally, such a method further comprises a needle having an interior bore. In such a method, the gastrointestinal organ may be considered to have a thickness. In the case of a gastrointestinal organ, the gastrointestinal tract of the subject may be considered to have center defined by a wall. The wall of the gastrointestinal tract may be considered to have a thickness defining an interior wall adjacent to the center and an exterior wall. The method may further comprise inserting a needle, such as a needle having an interior bore, into the thickness of the gastrointestinal organ. Optionally, in such a method the needle may be inserted until the end of the needle is positioned in the thickness of the wall between the interior wall and the exterior wall. The method may further comprise inserting a device through the interior bore of the needle. Optionally, in such a method, the device may have an engaging means. Optionally, such a method further comprises inserting the device until the engaging means extends beyond the interior bore of the needle into the thickness of the gastrointestinal organ. Optionally, such a method further comprises removing the needle. Optionally, such a method further comprises retracting the device. Optionally, such a method further comprises retracting the device until the engaging means engages the thickness. Such a method may thereby place the device in the gastrointestinal wall of the subject. Optionally the device may comprise an electrode, such as a stimulatory electrode. Optionally the device may comprise a sensor such as an electrical sensor. Optionally the device may comprise both an electrode and a sensor. Optionally, the device may comprise a plurality of electrodes. Optionally the device may comprise a plurality of sensors. Optionally the device may comprise a plurality of electrodes and one sensor. Optionally the device may comprise a plurality of sensors and one electrode. Optionally the device may comprise a plurality of electrodes and sensors.

Certain aspects of the disclosure provide methods of endoscopic placement or visualization of one or more electrode and/or sensor. Such a method can comprise using an endoscope for a variety of applications such as but not limited to: 1) visualization and insertion of electrodes and/or sensors with an endoscope 2) endoscopic visualization to guide insertion of the electrodes and/or sensors, 3) endoscopic insertion of electrodes and/or sensors wherein the observation of the placement is done with a colonoscope or laproscopically and 4) using a plurality of endoscopes for placement of electrodes or sensors (e.g. one endoscope to observe placement of an electrode and another endoscope to place the electrode and/or sensor). Optionally such a method may comprise the use of a single electrode and a single sensor or a plurality of electrodes and sensors or some combination thereof. Optionally, such methods further consist of a subject being sedated prior to or during the endoscopic visualization or placement of the electrode. Optionally, such methods further consist of inserting an endoscope or endoscopes in the gastrointestinal tract via the mouth. Optionally, in methods wherein observation of the placement of one or more electrode and/or sensor is contemplated, the methods may further comprise the insertion of a needle into the gastrointestinal tract from the exterior of the subject. Optionally, the methods further comprise a needle penetrating the gastrointestinal tract to the interior of the gastrointestinal tract or to the thickness of the wall of the gastrointestinal tract. In methods wherein a needle is contemplated, the needle may be a hollow needle with a hole in the middle such as a needle having a hollow interior bore. In other methods, a laproscope or trocar is contemplated to access the exterior of the gastrointestinal tract.

Certain aspects of the disclosure provide methods of colonoscopic placement or visualization of one or more electrode and/or sensor. Such a method can comprise using an colonoscope for a variety of applications such as but not limited to: 1) visualization and insertion of electrodes and/or sensors with a colonoscope 2) colonoscopic visualization to guide insertion of the electrodes and/or sensors, 3) colonoscopic insertion of electrodes and/or sensors wherein the observation of the placement is done with an endoscope or laproscopically and 4) using a plurality of colonoscopes for placement of electrodes or sensors (e.g. one colonoscope to observe placement of an electrode and another colonoscope to place the electrode and/or sensor). Optionally such a method may comprise the use of a single electrode and a single sensor or a plurality of electrodes and sensors or some combination thereof. Optionally, such methods further consist of a subject being sedated prior to or during the colonoscopic visualization or placement of the electrode. Optionally, such methods further consist of inserting a colonoscope or endoscopes in the gastrointestinal tract via the mouth. Optionally, in methods wherein observation of the placement of one or more electrode and/or sensor is contemplated, the methods may further comprise the insertion of a needle into the gastrointestinal tract from the exterior of the subject. Optionally, the methods further comprise a needle penetrating the gastrointestinal tract to the interior of the gastrointestinal tract or to the thickness of the wall of the gastrointestinal tract. In methods wherein a needle is contemplated, the needle may be a hollow needle with a hole in the middle such as a needle having an hollow interior bore. In other methods, a laproscope or trocar is contemplated to access the exterior of the gastrointestinal tract.

Certain aspects of the disclosure wherein placement of a device endoscopically through the esophagus and into a gastrointestinal organ is contemplated, the device may be implanted in the interior wall of the gastrointestinal tract. Optionally, the method comprises preparing an opening in the gastrointestinal tract from the interior wall of the gastrointestinal tract to access the wall of the gastrointestinal tract for implanting the device. Optionally, the method comprises creating a cavity in the wall of the gastrointestinal tract. Optionally, the method further comprises placing the device through the opening into the wall of the gastrointestinal tract. Optionally, the method further comprises closing the cavity. According to one variation, after preparing the opening in gastrointestinal tract, a pocket or cavity is prepared in the gastrointestinal tract to receive the device. Optionally, a knife, needle or cutting instrument may be used to prepare an opening in the wall of the gastrointestinal tract. Optionally, such a method further comprises injecting a material or solution into the opening for implanting the device, to form a bleb or blister in the gastrointestinal wall. Optionally, such a method may comprise the use of a tissue dissector to prepare a cavity. Optionally, the tissue dissector may be a blunt dissector, for example, a blunt tool, an expandable compliant or non-compliant balloon, or another mechanically expanding device, or a cutting blade. The dissector may also be a device using an energy source to break down or cut tissue such as an electrosurgical cutting or coagulating device, or an ultrasonic or laser device.

In certain aspects of the disclosure wherein a device is contemplated, the device may comprise an engaging means wherein the engaging means itself comprises a plurality of radially extendable arms positioned at an axis perpendicular, acute or obtuse to the insertion axis of the stimulator or sensor. The stimulator or sensor is inserted until the axis of the plurality of radially extendable arms extends beyond the interior bore of the needle, at which point the arms radially extend. The electrical stimulator is retracted until the radially extended arms engage the interior wall of the gastrointestinal tract. Optionally, the device may have 2, 3, 4, 5, 6, 7, 8, 9 or 10 radially extendable arms or more. Optionally each radially extendable arm may be positioned to the same angle. Without being limited to the particular example, each radially extendable arm may be positioned perpendicular or 90° from the insertion axis or 120° from the insertion axis or some angle between about 1° and 178° from the insertion axis. Alternatively, each radially extendable arm may be positioned to different angles. Without being limited to the particular example, one radially extendable arm may be positioned at an angle of about 1° from the insertion axis, another radially extendable arm may be positioned at an angle of about 60° from the insertion axis, another radially extendable arm may be positioned at an angle of about 90° from the insertion axis and another radially extendable arm may be positioned at an angle of about 136° from the insertion axis. Optionally, the plurality of radially extendable arms may be in the same plane. Alternatively, one or more radially extendable arms may be in a different plane as compared to another arm or arms. Without being limited to the particular example, two radially extendable arms may be at the terminal end of the device comprising an insertion axis wherein the device is positioned with the terminal end towards the center of the gastrointestinal tract, while three radially extendable arms may be positioned some distance away, such as 2-20 mm from the terminal end of the device along the insertion axis.

In other aspects of the disclosure wherein a device is contemplated, the device may be made of a soft plastic polymer or other medically acceptable non irritating material. Optionally, the device may be compressible. Optionally, the device may further comprise a plurality of electrodes and/or sensors. Optionally the device may be fixed by suture to the gastrointestinal tract. Alternatively, the device may be held stationary with respect to the gastrointestinal tract by a locking mechanism which surrounds wires leading to the stimulators or sensors and may be placed on the exterior wall of the gastrointestinal tract or on the skin of a subject. An example of a device that may be fixed or locked can be found in U.S. Pat. No. 5,292,344.

Certain aspects of the disclosure provide a for a device comprised of biocompatible materials that allow it to remain in the environment of the gastrointestinal tract or within the gastrointestinal tract wall for the life of the device, e.g., several weeks, months or years. Optionally, the electrode(s) or sensor(s) may comprise corrosion resistant metals and alloys such as, e.g. platinum, iridium, gold, tantalum, titanium, stainless steel or alloys of one or more of these metals, e.g., a platinum/iridium alloy. Other non-conductive parts of the device may comprise inert polymers, for example, from the polyolefin family, e.g., HDPE (high density polyethylene), PP (polypropylene), UHMWPE (ultra high molecular weight polyethylene), or fluoropolymer such as PTFE (polytetrafluoroethylene) FEP (fluorinated ethylene propylene) and other members. PMP (polymethylpentene), polysulfone, PMMA (polymethylmethacrylate) may also be used. Softer materials may be used, such as, e.g., silicones, C-Flex, polyurethanes, co-polymer nylons (e.g. PEBAX).

In other aspects of the disclosure wherein a device is contemplated, the device may comprise one or more stimulators and/or electrodes. Optionally such a device may further comprise a first and second pair of attachment members that secure the device in the gastrointestinal tract wall. Optionally, the first attachment members of the device are the first to enter the gastrointestinal tract wall. In such a device the attachment members may comprise a flexible material. Optionally the attachment members may be considered tines. Optionally the first tines may be considered leading tines that define an obtuse angle with respect to travel of the insertion axis of the device. Optionally, the leading tines have a diameter of about 1 mm and a length of about 3 mm. Optionally the second tines may define an angle which is obtuse, perpendicular or acute with respect to travel of the insertion axis of the device. Optionally, wherein the second tines are at an obtuse angle with respect to travel of the insertion axis of the device, the second pair of tines may or may not penetrate the gastrointestinal organ. Alternatively, wherein the second tines are at an acute or perpendicular angle with respect to travel of the insertion axis of the device, the second pair of tines may not penetrate the gastrointestinal tract wall. Examples of a device of this type may be found in U.S. Pat. No. 6,542,776. Such a device may be inserted into or through a gastrointestinal organ through a trocar from the exterior of the subject. Alternatively, such a device may be inserted from the exterior of a subject through a needle with a hollow bore wherein the flexible tines are compressed to be at an obtuse angle during insertion through the needle and into the wall of a gastrointestinal organ but are uncompressed or less compressed when exiting the hollow bore of the needle. Optionally, wherein the second tines are also at any angle relative to the insertion direction of the insertion axis of the device, they may be compressed inside of the hollow bore of a needle and uncompressed or less compressed when exiting the hollow bore of a needle.

In still other aspects of the disclosure wherein a device is contemplated, the device may be a device comprising stimulators and/or sensors and may be described in detail in U.S. Pat. No. 6,542,776. Such a device may comprise for example four electrodes which may be placed in contact with the interior or the exterior wall of the gastrointestinal tract. Optionally, such a device has electrodes supported by an electrode attachment member where the electrodes are in a plane with each other. One may envision four electrodes on a flat plate. Such an electrode attachment member may be attached to the gastrointestinal tract wall by sutures or staples. Optionally, the attachment member may have fixed tines at the point of placement of the attachment member to the wall of the gastrointestinal tract. Such fixed tines may be inserted into the thickness of a gastrointestinal organ in lieu of or in addition to sutures or staples in order to place the electrode attachment member. Optionally, the electrode attachment member further comprises an insertion axis extending through the electrode attachment member with a plurality of radially spaced arms as described above to place the electrode attachment member. Optionally, the electrode attachment member may be inserted to the body cavity or through the hollow bore of a needle. Optionally, the electrode attachment member may be constructed from a flexible material such as, e.g., silicone elastomer or similar material. The base materials for the electrodes which may act as stimulators and/or sensors may be comprised of platinum, platinum-iridium alloys, titanium and the like. The electrodes may optionally be in an uncoated state or may be coated with materials such as iridium oxide or titanium nitride or the electrodes may be platinized or carbonized. Optionally, the electrode attachment member has a substantially circular configuration. Alternatively, the electrode attachment member may be in any suitable configuration such as for example, square, oval, rectangular, etc. Optionally, the electrodes may be distributed around the distal surface equidistantly from the center of the distal surface.

In certain aspects of the disclosure wherein a device is contemplated, the device may be that which is disclosed in U.S. Pat. No. 7,076,306 which is hereby incorporated by reference in its entirety. In certain aspects of the disclosure wherein a device is contemplated, the device may be a distributed microsystem setup in which an implanted microsystem is sutured or otherwise attached to the exterior of a gastrointestinal organ. Such a device may be found in U.S. Pat. No. 7,720,539 which is hereby incorporated by reference. Optionally, such a device may incorporate a screw mechanism which may screw into the exterior of a gastrointestinal organ. Such a device may be found in U.S. Pat. No. 7,711,437 which is hereby incorporated by reference. In certain aspects of the disclosure wherein a device is contemplated, the device may include an expandable member that fixes electrodes in contact with the gastrointestinal tract wall. Optionally such a device is radially expandable. Optionally such a device may be able to expand radially when passed through the hollow bore of a needle. Optionally such a device may be inserted into the thickness of the wall of the gastrointestinal tract. Such a device may be found in U.S. Pat. No. 7,676,270 which is hereby incorporated by reference. Other examples of electrical stimulation devices that may be used according to the present disclosure are found in U.S. Pat. Nos. 7,599,736, 7,477,994, 7,363,084, 7,310,557, 7,203,551, 7,177,693 and 7,016,735 which are hereby incorporated by reference. Other examples can be found in U.S. Pat. Pub. Nos. 20070049793 and 20050251219 which are hereby incorporated by reference.

In certain aspects of the disclosure wherein a plurality of radially extendable arms is contemplated, the arms may be affixed to the insertion axis of the device. Optionally, arms may be affixed via a hinge mechanism. Optionally, the arms may be affixed via flexible resilient wires to the insertion axis.

In certain aspects of the disclosure wherein placement of a device is contemplated, the methods may comprise a gastrointestinal wall tunneling instrument. Optionally, such an instrument may further comprise an elongate tubular member having proximal and distal ends and a lumen extending therethrough and an elongate expandable member located at the distal end of the tubular member. The expandable member may have proximal and distal ends wherein the proximal end of the expandable member is connected to the distal end of the tubular member. The expandable member may be everted, such that the distal end of the expandable member is positioned within the lumen of the tubular member. An example of this type of method and instrument can be found in WO/2009/009276 and is herein incorporated by reference.

Certain aspects of the disclosure may pertain to a method of placing a device and an implantable device as demonstrated in FIG. 5. Referring to FIG. 5A, an electrode lead with an insertion axis 1 is inserted into a needle 2 with a hollow bore 3. The needle has an entrance tip 4 which may be inserted through the skin and into or through the wall of the gastrointestinal tract. The electrode lead 1 may have a first or a single pair of radially spaced arms 5. Optionally, such arms 5 are in an angular position which is more acute than when passed through the needle as shown in FIG. 5A. Referring to FIG. 5B the radially spaced arms 5 are in an angular position which is less acute than or perpendicular to the electrode lead with an insertion axis 1 when passed through the needle. Referring to FIG. 5C the lead 1 may have a second or additional pair of radially spaced arms 6 at a distance from the first pair of radially spaced arms 5. Referring to FIG. 5C, each pair of radially spaced arms 5 and 6 may be retracted to an angle more acute than when passed through the needle 2. Referring to FIG. 5D, the first pair of radially spaced arms 5 and the second or additional pair of radially spaced arms 6 may be in an angular position which is less acute or perpendicular when passed through the hollow bore 3 of the needle 2. Optionally, referring to FIG. 5E the lead 1 may have a second or additional pair of radially spaced arms 6 in the same plane from the first pair of radially spaced arms 5. Referring to FIG. 5E, each pair of radially spaced arms 5 and 6 may be retracted to an angle more acute than when passed through the needle 2. Referring to FIG. 5F, the first pair of radially spaced arms 5 and the second or additional pair of radially spaced arms 6 may be in an angular position which is less acute or perpendicular when passed through the hollow bore 3 of the needle 2. It is also contemplated that a lead 1 may have a plurality of radially spaced arms in an odd numbered configuration, such as for example three arms instead of the first or single pair of radially spaced arms 5 or the second or additional pair of radially spaced arms as referenced throughout FIG. 5.

Certain aspects of the disclosure concern placement of a device as shown in FIGS. 6A and B. Referring first to FIGS. 5A and 5B, an electrode lead with an insertion axis 1 and radially spaced arms 5 may be inserted through a needle 2 comprising a hollow bore 3 wherein the entrance tip of the needle 4 may be inserted through the skin and into or through the gastrointestinal wall which may alternatively be considered the wall of the gastrointestinal tract. Referring to FIG. 6A, the needle 2 with the hollow bore 3 is removed after insertion of the electrode lead with an insertion axis 1 comprising radially spaced arms 5 such that the lead extends through the skin 8, the panniculus 9 and into the gastrointestinal wall 10. Alternatively, referring to FIG. 6B, the lead extends through the skin 8, the panniculus 9 and through the gastrointestinal wall 10.

Certain aspects of the disclosure pertain to optimal spacing of a plurality of electrodes in the wall of the gastrointestinal tract or through the gastrointestinal tract. Referring to FIG. 6C a plurality of needles 2 may be connected via a bridge 7 such that a plurality of electrode leads with insertion axis 1 comprising radially spaced arms 5 are spaced an optimal distance from each other. The bridge may be any length that achieves optimal spacing. Optionally, the bridge 7 may allow separation of the needles 2 by a distance of 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10 mm or 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10 cm or some distance therein. Alternatively, referring to FIG. 7A, a needle 2 may first be inserted through the skin 9, the panniculus 9 and either into or through the gastrointestinal wall 10. A second needle 17 as shown in FIG. 7B may include a bridge 7 connected to a guide rod 11. Referring to FIG. 7C, the guide rod 11 may be inserted into the needle 2 and an electrode lead with an insertion axis 1 comprising radially spaced arms 5 may be inserted into the second needle. The guide rod 11 is inserted through the first needle 2 as the second needle is inserted through the skin 8, the panniculus 9 and into or through the gastrointestinal wall 10. Referring to FIG. 7C, the second needle 17 may be removed leaving in place an electrode lead with an insertion axis 1 comprising radially spaced arms 5 which may be located in the gastrointestinal tract or in the gastrointestinal wall 10. Also referring to FIG. 7C, a second gastrointestinal lead with an insertion axis 1 and a plurality of radially spaced arms 5 may now be inserted in the first needle where the guide rod was previously located. Referring to FIG. 7D, the first needle may be removed so that there is more than one electrode lead with an insertion axis 1 and a plurality of radially spaced arms 5 extending through the skin 8, the panniculus 9 and into or through the gastrointestinal wall 10.

Optionally, in certain aspects of the disclosure where placing of a device is concerned, the device may be a percutaneous endoscopic gastronomy type device. Referring to FIG. 8A, the device may comprise a skin bolster 12 attached or abutting the skin 8 and a gastric bolster 13 attached to or abutting the inside of the gastrointestinal wall 10. A plurality of electric leads 14 may be inserted through the skin bolster 12, through the panniculus 9 and through the gastrointestinal tract wall. The electric leads may be insulated and the lead ends 15 exposed and used as electrodes.

In certain aspects of the disclosure wherein an electrode lead with an insertion axis 1 comprising a plurality of radially spaced arms 5, the lead 1 and the arms 5 may be insulating a conductive wire 16 to serve as an electrode. Referring to FIG. 8B, an electrode lead with an insertion axis 1 comprising a plurality of radially spaced arms 5 which has been inserted through a needle 2 may have a conductive wire to serve as an electrode 16.

Certain aspects of the disclosure concern various means for maintaining the electrodes in position. Such other may include for example, anchors, sutures, anti-rotation mechanisms and device shape design.

In certain aspects of the disclosure wherein a device is concerned, the device may be constructed of a size and shape such that it can be deployed through the mouth and esophagus with the aid of an endoscope. Optionally, the stimulator is of a generally small profile when delivered to the implant site. Still further, the implant be constructed and/or implanted so that the device predictably maintains electrical contact with a muscle layer of the gastrointestinal tract wall. Optionally, the device may be constructed of a configuration or shape that prevents device rotation, or may be constructed so that device rotation or movement does not interfere with the electrode/muscle layer contact. Such a device may be found in WO/2002/089655 which is hereby incorporated by reference.

In certain aspects of the disclosure wherein placing a device is concerned, such methods may include a means for maintaining the device in proper orientation so that the electrodes, sensors or other transducers on the device maintain contact with a preferred area or layer of the gastrointestinal tract wall, for example, so that the electrodes, sensors or other transducers are preferentially facing a desired wall of the gastrointestinal tract within a submucosal space. An anti-rotation means may be provided that prevents rotation of the implant around axes that would move electrodes, sensors or transducers away from intimate contact with a desired area of the gastrointestinal wall, such as, e.g., a muscle layer or mucosal layer.

In certain aspects of the disclosure wherein placing a device is concerned, the shape of the device may, for example, have a broad aspect when viewing that side of the device intended to be in contact with a particular layer of the gastrointestinal tract wall (e.g., a muscle layer or mucosal layer); i.e., the top-view of the device has relatively large length and width dimensions with respect to the height dimension of the device given by its side-views. Optionally, the aspect ratio of the device, defined as the width of a side-view divided by the height of the device is larger than about 1, preferably larger than about 1.4 and more preferably larger than about 1.8.

In certain aspects of the disclosure wherein placing a device is concerned, an anti-rotation means may be provided that prevents rotation of the device about an axis parallel to an intended tissue plane of contact. A device in one variation is dimensioned so that the aspect ratio of the device viewed along an axis parallel to the intended plane of contact is greater than one and preferably greater than 1.4 and more preferably greater than 1.8.

The aspect ratio as used herein may be the width to height ratio of the aspect viewed along a particular axis. Alternatively, the anti-rotation device may comprise an extendible or expandable portion or member that extends into a position that prevents rotation of the electrodes away from contact with the muscle layer of the gastrointestinal tract wall.

In certain aspects of the disclosure wherein placing a device is concerned, an anti-rotation means may be provided that prevents rotation of the device about an axis parallel to a common plane on which the electrodes may lie. Accordingly, a device may be dimensioned so that the aspect ratio of the device viewed along an axis parallel to plane on which the electrodes may lie is greater than one and preferably greater than 1.4 and more preferably greater than 1.8. The device in this instance may be defined by a plane on which the electrodes lie.

In certain aspects of the disclosure wherein placing a device is concerned, the device may have a relatively small profile when placed through the wall or into the wall of the gastrointestinal tract and may be altered to have a different shape when implanted, to prevent rotation and/or provide optimal sensor/transducer/electrode contact with the gastrointestinal tract wall.

In certain aspects of the disclosure wherein the device is contemplated, the device may be designed to promote encapsulation or tissue ingrowth, e.g. by choice of material, coatings or surface texture. Optionally an electrode(s) or sensor(s) or surrounding area may be coated with a material such as P-15, which is a commercially available compound that promotes cellular adhesion and tissue ingrowth.

In certain aspects of the disclosure wherein the device is contemplated, the device or portions of the device may be constructed of or coated with substances that inhibit tissue ingrowth.

Also provided is a method of treatment for an eating disorder, in an individual in need thereof, the method comprising positioning stimulatory electrodes in contact with the distal small intestine or ileum; and administering electrical stimulation, wherein the electrical stimulation is effective, at least in part in, stimulating the vagal afferent and efferent activity, of the distal small intestines or ileum, in the individual. In general, the stimulation of the vagal afferent and efferent activity regulates the ileal brake. Specifically, the eating disorder is selected from the group consisting of obesity, bulimia and compulsive eating.

Furthermore, provided herein is a method of treatment for a metabolic disease, in an individual in need thereof, comprising positioning stimulatory electrodes in contact with the distal small intestine or ileum, and administering electrical stimulation wherein the electrical stimulation is effective, at least in part in, stimulating the vagal afferent and efferent activity, of the distal small intestines or the ileum, in the individual. In general, the stimulation of the vagal afferent and efferent activity regulates the ileal brake. Specifically, the metabolic disease is diabetes. The disclosure may be embodied in other specific forms without departing from its spirit or essential characteristics. The described embodiments are to be considered in all respects only as illustrative and not restrictive. The scope of the disclosure is, therefore, indicated by the appended claims rather than by the foregoing description. All changes to the claims that come within the meaning and range of equivalency of the claims are to be embraced within their scope. Further, all published documents, patents, and applications mentioned herein are hereby incorporated by reference, as if presented in their entirety.

EXAMPLES Example 1 The Effects of Ileal Electrical Stimulation on Proximal Gastric Tone

Six dogs chronically, implanted with a gastric canula (for the placement of a barostat balloon into the proximal stomach) and one pair of stimulation electrodes in the distal ileum, were used for the study. Gastric tone evaluated by barostat was measured in the fasting state at baseline (30 minutes) and during ileal electrical stimulation (IES, 30 minutes of long pulses), with a frequency of 20 pulses/minute, pulse width of 200 ms and amplitude of 6 mA.

IES resulted in proximal gastric distention. Gastric volume was substantially and significantly increased from 123.2̂10.2 ml at baseline to 355.7+0.68.0 ml during IES (p=0.023), as shown in FIG. 1. The IES-induced gastric distention is expected to activate stretch receptors, resulting in a satiety signal.

Example 2 The Effects of Ileal Electrical Stimulation on Gastric Emptying

A duodenal cannula, used to collect gastric output for the assessment of gastric emptying (Phenol Red) was chronically placed, in five pigs, at the duodenum 10 cm below the pylorus. One pair of electrical stimulation electrodes was implanted in the distal ileum. The experiment was performed in two randomized sessions at an interval of at least 2 days: one control session without IES and one session of IES with similar parameters used in the canine study. Emptied gastric content was collected from the cannula every 15 minutes for a period of 90 minutes.

Gastric emptying was dramatically and significantly inhibited with IES (FIG. 2). The delayed gastric emptying is expected to lead to a reduction in food intake.

Example 3 The Effect of Ileal Electrical Stimulation (IES) on Food Intake in Dogs

This study was composed of two sessions (control and IES) and performed in 5 dogs. All the animals were subjected to five days of acclimation during which food was given only at a specific time. Following acclimation, the animals were subjected to 5-day sham IES and 5-day IES. During these study days, the animals were given food only for a period of 2 hours daily and IES or sham IES was performed during the 2-hr feeding period. The stimulation parameters used were 40 Hz, 2 ms, 2 s on/3 s off and 8.0 V.

IES was effective in significantly reducing food intake by 63% in comparison with sham IES (528.5±15.0 g vs. 197.3±8.3 g, p<0.001).

Although preferred embodiments have been depicted and described in detail herein, it will be apparent to those skilled in the relevant art that various modifications, additions, substitutions and the like can be made without departing from the spirit of the invention and these are therefore considered to be within the scope of the invention as defined in the claims which follow.

REFERENCES

The following references, to the extent that they provide exemplary procedural or other details supplementary to those set forth herein, are specifically incorporated herein by reference.

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What is claimed is:
 1. A method of treatment for obesity, in an individual in need thereof, said method comprising: positioning a pair of stimulatory electrodes in contact with the distal small intestine or ileum of said individual; and administering electrical stimulation, wherein said electrical stimulation is effective, at least in part in, stimulating the vagal afferent and efferent activity, of the distal small intestines or ileum, in said individual.
 2. The method of claim 1, wherein said stimulation of the vagal afferent and efferent activity regulates the ileal brake.
 3. The method of claim 1, wherein the electrical stimulation is administered in trains of pulses.
 4. The method of claim 3, wherein said electrical stimulation is composed of trains of pulses, with a train on time from 0.1 s to 10 s, train off time from O s to 10 s, and pulses in each train with amplitude of 0.1 mA to 20 mA (or voltage equivalent), width of 0.1 ms to 20 ms and frequency of 0.1 Hz to 200 Hz.
 5. The method of claim 3, wherein said electrical stimulation is composed of repetitive long train of pulses with a width of 5 ms to 2000 ms, amplitude of 0.1 mA to 20 mA and frequency of 1 pulse/min to 60 pulses/min.
 6. (canceled)
 7. The method claim 1, wherein said pair of stimulatory electrodes are positioned about 1 cm to 10 cm apart.
 8. The method claim 1, wherein said individual suffers from a functional gastrointestinal disease.
 9. The method of claim 8, wherein said functional gastrointestinal disease is selected from the group consisting of functional dyspepsia, irritable bowel syndrome, diarrhea, constipation, fecal incontinence, visceral hypersensitivity and visceral pain.
 10. The method of claim 1, wherein said individual suffers from an eating disorder.
 11. (canceled)
 12. The method of claim 1, wherein said individual suffers from diabetes.
 13. A method of treatment for functional gastrointestinal disease, in an individual in need thereof, said method comprising: positioning stimulatory electrodes in contact with the distal small intestine or ileum; and administering electrical stimulation, wherein the electrical stimulation is effective, at least in part in, regulating gastric emptying.
 14. The method of claim 13, wherein said functional gastrointestinal disease is selected from the group consisting of dumping syndrome, postprandial hyperglycemia, irritable bowel syndrome, diarrhea, visceral hypersensitivity and pain.
 15. The method of claim 13, wherein said electrical stimulation is composed of short trains of pulses, with a train on time from 0.1 to 10 s, train off time from 0 to 10 s, and pulses in each train with amplitude of 0.1 to 2 OmA (or voltage equivalent), width of 0.1 ms to 20 ms and frequency of 0.1 Hz to 200 Hz.
 16. The method of claim 13, wherein said electrical stimulation is composed of repetitive long train of pulses with a width of 5 ms to 2000 ms, amplitude of 0.1 mA to 20 mA and frequency of 1 to 60 pulses/min.
 17. The method of claim 13, wherein said pair of stimulatory electrodes are positioned about 1 cm to 10 cm apart.
 18. (canceled)
 19. The method of claim 13, wherein said electrical stimulation activates the vagal afferent and efferent activity, of the distal small intestines or ileum, in said individual.
 20. The method of claim 19, wherein said stimulation of the vagal afferent and efferent activity regulates the ileal brake.
 21. (canceled)
 22. (canceled)
 23. (canceled)
 24. A method of treatment for a metabolic disease, in an individual in need thereof, comprising: positioning stimulatory electrodes in contact with the distal small intestine or ileum, and administering electrical stimulation wherein the electrical stimulation is effective, at least in part in, stimulating the vagal afferent and efferent activity, of the distal small intestines or the ileum, in said individual.
 25. The method of claim 24, wherein said stimulation of the vagal afferent and efferent activity regulates the ileal brake.
 26. The method of claim 25, wherein said metabolic disease is diabetes. 